Pilonidal sinus disease with especial reference to Limberg flap

This article lays an emphasis on “Pilonidal Sinus disease” along with the historical background, materials, and methods used. The term ‘Pilonidal’ was coined by Hodge in 1880. The disease commonly affects middle-aged working population and most often arises in the hair follicles of the natal cleft of the sacrococcygeal area. This disease affects males thrice as much as females because of their hirsute nature. Pilonidal sinus is associated with obesity, sedentary occupation, and local irritation or trauma. The management of pilonidal disease is complex and a big burden on hospital and community resource because of the recurrent nature of the disease. Various surgical methods have been practiced to treat sacrococcygeal pilonidal sinus disease. Each method is associated with different postoperative complications, morbidity, and recurrence rates for each of the procedures.

The most simple approach for pilonidal disease is simple incision. It is effective for simple, superficial, small, and mostly midline tracts. Excision is a simple technique used for chronic and recurrent pilonidal sinuses. Rhomboid Limberg flap reconstruction plastic surgery procedure was done after proper preoperative assessment and preparation in all cases.

1. Pilonidal sinus disease with especial reference to Limberg
flap

2. Review Article
Pilonidal sinus disease with especial reference to
Limberg
flap
Ajay K. Khanna
a,
*,
Satyendra K. Tiwary
b
a
Professor, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi,
Uttar
Pradesh 221005, India
b
Assistant Professor, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University,
Varanasi,
India
1. Background
First historical description of pilonidal disease dates back to
1833
by Herbert Mayo as a hair containing sinus
1
but the term
'Pilonidal'
was coined by Hodge in 1880.
2
The disease is a very
common
problem affecting middle-aged working population,
and
it most often arises in the hair follicles of the natal cleft of
the
sacrococcygeal area. Incidence of pilonidal sinus is about
26
cases per 100,000, affecting males thrice as much as
females.
Men are thought to be at higher risk because of their
hirsute
nature. Pilonidal sinus is also associated with obesity
(37%),
sedentary occupation (44%), and local irritation or
trauma
(34%).
3
It may manifest as pilonidal cyst, sinus, or
abscess,
and inflammation may lead to rapid progression of
the
disease. During the Second World War, pilonidal disease
very
commonly appeared in jeep drivers, so called as ‘‘jeep
disease’’.
4
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x
a r t i c l e i n f o
Article history:
Received
30 June 2015
Accepted
28 July 2015
Available
online xxx
Keywords:
Pilonidal
sinus
Jeep
disease
Limberg
flap
Epidemiology
Bacterial
contamination
a b s t r a c t
This article lays an emphasis on ‘‘Pilonidal Sinus disease’’ along with the historical back-
ground,
materials, and methods used. The term 'Pilonidal' was coined by Hodge in 1880. The
disease
commonly affects middle-aged working population and most often arises in the hair
follicles
of the natal cleft of the sacrococcygeal area. This disease affects males thrice as
much
as females because of their hirsute nature. Pilonidal sinus is associated with obesity,
sedentary
occupation, and local irritation or trauma. The management of pilonidal disease is
complex
and a big burden on hospital and community resource because of the recurrent
nature
of the disease. Various surgical methods have been practiced to treat sacrococcygeal
pilonidal
sinus disease. Each method is associated with different postoperative complica-
tions,
morbidity, and recurrence rates for each of the procedures.
The
most simple approach for pilonidal disease is simple incision. It is effective for
simple,
superficial, small, and mostly midline tracts. Excision is a simple technique used for
chronic
and recurrent pilonidal sinuses. Rhomboid Limberg flap reconstruction plastic
surgery
procedure was done after proper preoperative assessment and preparation in all
cases.
#
2015 Published by Elsevier B.V. on behalf of Indraprastha Medical Corporation Ltd.
*Corresponding
author. Tel.: [phone].
E-mail
address: [email protected] (A.K. Khanna).
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ScienceDirect
journal homepage: www.elsevier.com/locate/apme
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0976-0016/#
2015 Published by Elsevier B.V. on behalf of Indraprastha Medical Corporation Ltd.

3. Pilonidal disease can appear as an acute abscess along
with
sinus tract formation. There have been a lot of debate on
whether
pilonidal disease is congenital or acquired, but now it
is
beyond doubt that it is an acquired condition.
5,6
A more
complex
manifestation usually after episode of inflammation
can
be characterized by chronic or recurrent abscesses with
extensive
branching sinus tracts. The commonest presenta-
tion
for which a patient seeks medical advice is in the form of
an
acute abscess characterized by the existence of a midline
pit
in the natal cleft typically identified 4–8 cm from the anus.
A
deep natal cleft serves favorable atmosphere for bacterial
colonization
due to anaerobic environment, sweating, hair in
growth,
close proximity to bacteria leading to contamination.
This
primary tract leads into a subcutaneous cavity, which
contains
granulation tissue and usually a nest of hairs that are
present
in two thirds of cases in men and in one third of those
in
women and may be seen projecting from the skin opening.
Many
patients have secondary lateral openings 2–5 cm above
the
midline pit. The skin opening and the superficial portion
of
the tract are lined with squamous cell epithelium, but the
deep
cavity and its extensions are not. Maximum number of
cases
of pilonidal sinus are present in postsacral area, but it
may
be seen in other regions such as interdigital, axillary,
umbilical,
peri-anal, para-anal, intra-anal, and cervical
region.
7,8
The management of pilonidal disease is complex and a big
burden
on hospital and community resource because of the
recurrent
nature of the disease.
9,10
Treatment and prevention
are
successful, if causative factors such as deep natal cleft and
presence
of hair are taken care or minimized to prevent
sweating,
maceration, bacterial contamination, and penetra-
tion
of hairs.
11,12
Proper decision making is based on the type
of
presentation and treatment modality that range from
antibiotics,
shaving, simple incision and drainage, phenol
application,
cryosurgery, excision with primary closure,
excision
with open packing, and excision with marsupializa-
tion
to a wide excision with reconstructive surgical proce-
dures.
13–16
There is no clinical consensus on the optimal management
of
the pilonidal sinus but low recurrence, low morbidity,
acceptable
cosmesis, insignificant tissue loss, and minimal
economic
loss should be the goal in management. Our
experiences
are mostly with reconstructive procedure of
Limberg
flap in 180 patients of pilonidal disease from year
2004
to 2014.
2. Materials and methods
Retrospective data analysis of 180 patients during 2004–2014
was
done. Detailed demographics, epidemiology, and clinical
presentations
were analyzed. Only cases with surgical inter-
ventions
were considered for study. Conservative manage-
ment
by antibiotics and drainage of pus was carried out in
abscess,
and these patients were later subjected to rhomboid
excision
Limberg flap reconstruction.
Age,
sex, duration, co-morbidity, presentation, number of
openings,
number of surgical interventions in past, treatment,
duration
of hospital stay, complications, and follow-up were
recorded
and analyzed (Table 1).
3. Results
In 180 patients, males were 126 (70%), and females were 54
(30%).
Mean age of presentation was 24.2 years (15–65 years)
with
mean BMI of 22.3 kg/m
2
(17.1–30.5). Co-morbidity was
present
in 42 patients (23.3%) in the form diabetes, renal
failure,
and immunocompromised patient. Recurrent disease
with
history of past surgical intervention was noticed in 36
patients
(20%). Most significant finding was history of
previous
infection or abscess in 171 patients (95%). Single
tract
was in 153 patients (85%) and multiple tract in 27 (15%).
All
patients underwent surgical intervention by Limberg flap
reconstruction.
Mean hospital stay was 3.2 days (1–9 days)
and
mean follow-up of 38.4 months (6–60 months). Recur-
rence
was noticed in only 6 cases (3.3%). Outcome and follow-
up
in pilonidal disease treated by Limberg Flap is shown in
Table
2.
Surgical
excision and rhomboid Limberg flap reconstruc-
tion
plastic surgery procedure (Figs. 1–4) were done after
proper
preoperative assessment and preparation in all cases.
First
and foremost measure was control of inflammation and
infection
in all cases with antibiotics and drainage with
incision
and debridement. Anatomical mapping with fistulo-
gram
preoperatively in all cases was done to plan reconstruc-
tive
procedures. Fistulogram delineated the number of tract,
depth
of cavity and lateral extension leading to proper
planning
of extent of rhomboid flap excision for curative
intent.
Hairs over the region were shaved preoperatively in all
cases.
Spinal anesthesia was used in 171 cases (95%) and local
anesthesia
in 9 cases (5%). Position was jackknife prone in all
Table 1 – Demographics of pilonidal disease (n = 180).
Total, n, % 180 (100%)
Male,
n, % 126 (70%)
Female,
n, % 54 (54%)
Age,
years Mean 24.2 (15–65)
BMI
Mean 22.3 (17.1–30.5)
Comorbidity
(Diabetes,
Immuno
compromised,
Renal
failure), n, %
42
(23.3%)
Recurrent
disease, n, % 36 (20%)
Previous
infection or abscess, n, % 171 (95%)
Single
tract, n, % 153 (85%)
Multiple
tracts, n, % 27 (15%)
Hospital
stay Mean, 3.2 days (1–9 days)
Follow-up
Mean 38.4 months
(6
months to 60 months)
Recurrence,
n, % 6 (3.3%)
Table 2 – Outcome and follow up in pilonidal disease
(n
= 180).
Seroma 2 (1.1%)
Hematoma
6 (3.3%)
Wound
dehiscence 8 (4.4%)
Flap
necrosis 1 (0.5%)
Wound
infection 4 (2.2%)
Residual
pain and heaviness 9 (5%)
Recurrence
6 (3.3%)
Hypoasthesia
8 (4.4%)
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x2
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4. cases. After prepping and draping, lesion was marked and
included
in rhomboid area to be excised. Limberg flap was
raised
as per the dimensions to cover the defect. The flap was
raised
along with the fascia over the gluteus maximus. Two-
layered
closure was done with vicryl 2-0 for adipofacial
approximation
and prolene 3-0 for skin closure. Minivac
suction
drain was placed after hemostasis in 160 cases (88.1%).
The
patient was nursed in prone position or lateral position for
initial
24 h. The dressing was changed after 48 h and the drain
was
removed if contents were less than 10–15 ml.
Fig. 1 – Planning of Rhomboid or Limberg Flap
Fig. 2 – Marking, incision and excision
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 3
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5. 4. Discussion
Various surgical methods have been practiced to treat
sacrococcygeal
pilonidal sinus disease; each is associated
with
different postoperative complications, morbidity, and
recurrence
rates for each of the procedures. Excision of the
infected
tissue and sinuses is not considered a major technical
problem
but healing is cumbersome and expensive for both
the
patient and physician due to its long duration and the
Fig. 3 – Incision and mobilization of Limberg Flap
Fig. 4 – Closure in Limberg Flap
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x4
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6. requirement for daily wound dressings using the open-
packing
technique.
17
Although the primary closure method
results
in rapid recovery and quick resumption of daily
activities,
high complication and recurrence rates have been
reported.
18,19
Pilonidal disease affects men
20,21
between 16 and 25 years
of
age. Usually it is associated with obesity
22,23
and hirsute
individuals,
who experience profuse sweating and have a
sedentary
lifestyle.
24,25
High morbidity and chronicity of the
disease
leads to significant economic burden. In acute phases
of
inflammation, an antibiotic and conservative approach is
the
choice. There is almost always history of inflammation or
abscess
formation. Definitive and curative approach always
includes
some type of surgical intervention. The treatment of
pilonidal
disease is mostly surgical. The most commonly used
procedures
today are simple incision, excision, marsupializa-
tion,
fistulotomy, and various plastic surgery techniques.
Most
simple approach for pilonidal disease is simple
incision.
It is basically a limited intervention in acute
inflammatory
stage and is most important for relieving pain
and
rapid recovery for subsequent definitive excision and flap
reconstruction
surgery. A midline incision through the
mouths
of the pits carried out and is effective in those cases
of
so-called raphe cannulization where infection spreads from
pit
to pit.
26,27
It is effective for simple, superficial, small, and
mostly
midline tracts. After unroofing the tract, it is debrided,
cleaned,
and drained.
28,29
Recurrence is frequent, and defini-
tive
plastic reconstructive procedure is planned for final cure.
Excision
is a simple technique used for chronic and
recurrent
pilonidal sinuses. Excision of all involved skin and
subcutaneous
tissue is must for definitive treatment. Wounds
may
be left open with healing by secondary intention, allowing
the
wound to granulate, or is closed by primary intention with
immediate
suturing.
30,31
Various types of silastic dressing and
negative
pressure therapy are used to fasten the healing of
wound.
Laying the sinus open permits adequate drainage of
secretions,
pus, or debris. The healing by secondary intention
requires
more time, but has lower recurrence rate.
32
In healing
by
primary intention, the pilonidal sinus is excised and the
wound
sutured by using deep tension sutures tied over a gauze
dressing.
The advantages are quicker healing, less hospital
stay,
and an early return to work, albeit with higher recurrence
when
compared to the open technique.
33,34
Plastic surgery techniques that include these procedures do
not
only cover the wound but also, in theory, flatten the natal
cleft,
as well as reduce hair accumulation, mechanical
irritation
and risk of recurrence.
20,35
Various kinds of flaps
have
been used: 1–2 skin flaps, fasciocutaneous flaps like the
V-Y
flap (for recurrent and complicated sinus disease) and
rhomboid
excision and the Limberg flap.
6
The Karydakis flap
36
achieves asymmetric closure of the pilonidal wounds by
avoiding
to place the wound in the midline at the depth of the
natal
cleft and also flattens the cleft, reducing hair accumula-
tion
and mechanical irritation
36,37
resulting in decreased
recurrence.
A
tendency toward using flap reconstruction techniques to
treat
pilonidal sinus has been established, as they provide the
desired
results, such as flattening of the natal cleft, providing
tissue
healing without tension, short duration of healing
and
return to work, acceptable cosmetic results, and low
recurrence
rates.
38
The problem, related to a continuing deep
natal
cleft after surgery, leads surgeons to find techniques in
order
to minimize or flatten natal cleft. Infection starts in hair
follicles
due to open orifices leading to sinus as hypothesized
by
Bascom and excision of midline pits with lateral open
drainage
of any associated abscess essential for cure. Natal
cleft
effect, wound tension, and complete excision are three
key
factors that prompted various plastic reconstructive
procedures
such as Z plasty, W plasty, V-Y plasty, and various
flap
techniques. Various techniques have been described that
attempt
to eliminate factors that cause negative primary
closure
results such as a midline incision scar and tissue
tension
resulting in lower recurrence rates.
12,20,39–42
One of
the
most commonly used techniques is Limberg flap
reconstruction.
The
flap necrosis after Limberg flap is rare, and it varies from
0
to 3.3% of cases in literature.
43
In our study, only one patient
out
of 180 had partial flap necrosis, which is acceptable and
comparable
to various studies in past. The rate of development
of
seroma after Limberg flap is 0–14.5% of cases in various
studies.
Mentes et al. reported a seroma rate of 2.2% without
placing
a drain and a mean duration of hospitalization of 4.51
ş
2.85 days in their series of 353 patients.
44
Kirkil et al. reported
the
rates of seroma development in groups with and without
drains
to be 10.7 and 18.5%, respectively (total, 14.5%), in their
series
of 55 patients who were randomized for drain placement
with
a mean 3.2 days of hospitalization.
45
They reported that all
such
patients were treated by repeated aspiration of seroma.
Okuş
et al. reported a mean duration of hospitalization of 1.85
days
and that no seroma developed in any patient treated with
Limberg
flap in their prospective study of 49 patients in an
Limberg
flap group in which drains were placed in all patients.
46
Therefore, these studies suggest no relationship between
development
of a seroma and duration of hospitalization. We
discharged
our patients 24–48 h after surgery with a mean of 3.2
days
(1–9 days). The rates of hematoma and wound dehiscence
after
Limberg flap are 0–4% and 0–10.4%, respectively, and in our
patients,
such were 3.3 and 4.4%. Although hematomas have
been
treated with repeated aspiration in some studies, but good
hemostasis
is the key to prevent hematoma.
45
The rate of wound infection after the Limberg flap
procedure
varies from 0–8% of cases.
43
Different rates of
infection
in studies with similar numbers of patients and
duration
of hospitalization have been reported, suggesting
that
there is no direct relationship between the duration of
hospitalization
and the development of infection. The rate of
infection
was 2.2% (4 patients) in our series of 180 patients.
The
most commonly reported result in long-term studies is
the
recurrence rate. The reported rates of recurrence following
Limberg
flap vary between 0 and 9%.
43
Two other long-term
problems
with Limberg flap are hypoesthesia at the operative
site
and cosmetic dissatisfaction. Mentes et al. reported a
recurrence
rate of 2.2%.
44
The rates of recurrence and
hypoesthesia
in our study agree with those in the literature
(3.3
and 4.4%, respectively).
Short-
and long-term postoperative results are in agree-
ment
with the literature data in patients treated with the
Limberg
flap procedure in our study. The duration of
hospitalization
varies from 1.7 to 5.9 days
43,44
in studies in
which
Limberg flap was performed.
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 5
APME-309; No. of Pages 7
Please cite this article in press as: Khanna AK, Tiwary SK. Pilonidal sinus disease with especial reference to Limberg flap, Apollo Med.
(2015),
http://dx.doi.org/10.1016/j.apme.2015.07.013

7. 5. Conclusion
Pilonidal sinus is a benign disorder but two serious issues are
associated
with it; those are significant economic loss and
significant
morbidity. It affects the working middle-aged
population
and individuals receiving their education or those
in
early phases of their job. The time spent in the hospital
continues
to result in significant economic issues. The Limberg
flap
procedure has minimal postoperative complications and
very
low recurrence in long-term follow-up with minimal time
to
be spent in hospital. Though it requires a good geometric
calculation
for raising the flap, the flap never fails with an
advantage
of flattening natal cleft so to have the low
recurrence
of the disease.
Conflicts of interest
The authors have none to declare.
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APME-309; No. of Pages 7
Please cite this article in press as: Khanna AK, Tiwary SK. Pilonidal sinus disease with especial reference to Limberg flap, Apollo Med.
(2015),
http://dx.doi.org/10.1016/j.apme.2015.07.013